By Tian Johnson, African Alliance
Universal Health Coverage Day was created to remind the world of a simple promise: everyone should be able to get healthcare without being pushed into debt.
But in Africa, that promise still feels far away. Even as the continent’s population races towards 2.5 billion people by mid-century, access to basic services is crawling forward at a pace that doesn’t match the need.
The World Health Organisation estimates that Africa is only just approaching the halfway mark to achieving universal health coverage.
Millions still can’t get the care or medicines they rely on.
And that’s the heart of the crisis: even when people finally reach a clinic, they’re often sent home with a list of medicines they must buy themselves and which they often cannot afford.
Across the continent, families are being tipped into poverty by everyday illnesses because health systems are so thinly funded that the cost is shifted onto ordinary people.
Nearly three decades of broken promises
African governments have been making bold promises on health for more than two decades and each promise has carried the same simple message: people shouldn’t go broke because they get sick.
Back in 2001, the Abuja Declaration was a promise that governments would put 15% of their national budgets toward health, but most don’t. Many spend half that or less. The result is empty medicine shelves, clinics that can’t offer the basics and a system that lean on the pockets of the poor.
By the early 2020s, the gap between political promises and what governments were actually funding had grown so wide that new frameworks were urgently needed to bring financial protection back to the centre of health policy.
In 2023, the consequences of this failure had become painfully clear. So African leaders returned to the table and signed the Lusaka Agenda, this time naming the crisis plainly: people are being pushed into poverty by the cost of medicines. The Lusaka Agenda was designed to hard-wire financial protection into health systems by urging governments to finally meet their Abuja funding commitments and to adopt reforms that would bring down medicine prices for good.
The Lusaka Agenda set the direction. What remained was turning continental commitments into binding, trackable national action. Then, in October this year, African governments went a step further with the Durban Promise, which created a Pan-African Health Financing commitment framework that would hold governments accountable for the financing commitments they keep delaying, and to ensure that continental pledges translate into national budgets, stocked clinics and affordable medicines where people actually live.
The question now is whether these promises will finally move from conference halls into clinics or whether, twenty years from now, another generation will be rewriting the same commitments while patients continue to pay the price.
Medical bills keep people poor
If you’ve ever spoken to people waiting outside a clinic, you’ll know the story: “The nurse saw me, but they had no stock. Now I must find the money.”
Medicines are the single biggest reason households slip into medical debt. Globally, they make up more than half of what families pay when they get sick. For the poorest households, it’s even more.
Out-of-pocket payments (the money families spend directly when they get sick) have shot up across the region.
Every year, 11 million Africans fall into poverty because of health expenses alone. With donor funding declining at the same time as economies wobble, as many as 39 million more people could face the same fate by 2030. These pre-COVID estimates – and several analyses – suggest the true numbers may now be even higher.
Africa is hit especially hard because almost everything (vaccines, pills, medical devices) is imported.
More than 90% of vaccines used on the continent are bought abroad.
Seventy percent of all medicines come from outside Africa. When global supply chains crack or prices climb, African patients feel it instantly.
If the public clinic has run out, people must turn to private pharmacies, where prices can be wildly out of reach.
There are two possible fixes, both doable and urgent.
Make essential healthcare and medicines free for the poor
Many African countries could begin doing this right now, especially by prioritising the poorest households, without destabilising their budgets.
The poorest households already shoulder the most crushing costs even though they have the least ability to pay. The cost of exempting the lowest income groups from essential medicines is far smaller than many assume because they represent the largest share of medical impoverishment but the smallest share of national income.
Lifting the cost burden from them is both fair and financially possible, and it would pull millions back from the edge of poverty.
Countries like Rwanda have already shown what’s possible when governments commit to building strong, home-grown systems.
Their community health insurance model, which covers most of the population, is proof that African solutions can work at scale.
And there are other ways to bring in more public money.
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This matters because many African governments face shrinking fiscal space as debt servicing consumes a growing share of national budgets.
A small solidarity charge on every airline ticket leaving African airports, for example, could raise between $500 and 700 million a year, according to an Africa CDC concept note published in April. This revenue, dependent on political agreement and implementation, shows what is possible when the continent adopts shared financing mechanisms. And that’s money that could go straight into basic services and medicine budgets.
But these kinds of steps need planning. Only a third of African countries have up-to-date national health plans with proper costing. Without them, raising and managing public funds becomes far harder.
Buy medicines together, not country by country
The second solution tackles the deeper problem: the high cost of medicines.
Africa’s reliance on global suppliers means each country is negotiating alone against far stronger markets, which keeps prices high.
When each country buys supplies alone, they pay more. When countries band together, they gain bargaining power and can push prices down.
Regional pooled procurement is already being tested. Small island states like Cabo Verde, Comoros and Mauritius are now joining forces to buy medicines as a group so they can stop overpaying simply because they are small markets. Central African countries are developing similar models.
This shift is part of a broader push under the Lusaka Agenda, which urges donors and governments to work to a single national plan, a single budget and a single reporting system.
If donor support were aligned in this way, up to $3 billion a year could be released directly into strengthening health systems and reducing medicine costs.
The goal is simple: to make Africa less vulnerable to shocks and less dependent on expensive imports.
The promise of UHC must not be broken
Africa’s medical debt crisis is not an accident. It’s the predictable result of health systems funded too lightly, medicines priced too high and families forced to cover the gap. But it is solvable.
Give the poorest households free access to the care and medicines they rely on. Buy essential supplies as a continent, not as 55 isolated markets.
Do those two things, and Universal Health Coverage stops being a slogan and starts being something people can feel in their daily lives.
UHC is about the mother who doesn’t have to choose between buying antibiotics and buying food. It’s about a pensioner who doesn’t have to pawn their phone to pick up their blood-pressure pills. It’s about dignity and the promise that getting sick shouldn’t mean going broke.
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Tian Johnson is the founder and strategist of the Pan-African health justice advocacy group, African Alliance.
The views and opinions expressed in this opinion piece are those of the author, who is not employed by Health-e News. Health-e News is committed to presenting diverse perspectives to enrich public discourse on health-related issues.
